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oPatientPlus articles are written by UK doctors and are based on research evidence, UK and European Guidelines. They are designed for health professionals to use, so you may find the language more technical than the condition leaflets.

Primary non-lymphoproliferative tumours of the spine are uncommon and make up less than 5% of bone neoplasms.

Metastatic disease of the spine is much more common. Approximately 40-80% of patients who die from cancer have bony metastases at the time of death, with the spine being the most common metastatic skeletal location. Problems can be caused by direct compression on the spinal cord, vascular obstruction and invasive infiltration.

In children, the common benign tumours include osteoid osteomas and osteoblastoma.

However, they are the most common primary malignant tumour of the spine in the adult, excluding lymphoproliferative tumours and metastases.

Presentation is often subtle with a gradual onset of pain, numbness, motor weakness and constipation or incontinence.

Constipation is a uniform finding in most patients with sacrococcygeal lesions.

Chordomas are slow-growing lesions and are often very large at the time of presentation.

Round cell tumour:

Ewing's sarcoma - Ewing's sarcoma is the most common non-lymphoproliferative primary malignant tumour of the spine in children:

Patients with Ewing's sarcoma usually present aged 10-20 years.

The most common site of occurrence in the spine is the sacrococcygeal region.

When classifying benign lesions they may be:

Latent (stage 1)

Active (stage 2)

Aggressive (stage 3)

Stage 1 lesions are usually asymptomatic and are discovered incidentally. Stage 2 lesions usually present with symptoms; most commonly, pain is in the area of the lesion. Stage 3 lesions are locally aggressive and can actually metastasise.[1]

Metastatic tumours

Approximately 30% of patients with cancer develop symptomatic spinal metastases during the course of their illness. Up to 90% of cancer patients have metastatic lesions within the spine at the time of death.[2] The most common tumours that metastasise to the spine are as follows:[1]

Presentation

Symptoms

Systemic or constitutional symptoms tend to be more common with malignant or metastatic disease than in benign lesions.

Symptoms usually develop slowly.

Back pain is the most frequent symptom for patients with either benign or malignant neoplasms of the spine:

With extradural lesions pain is typically aggravated by coughing or straining.

It may be radicular, localised to the back or felt generally in an extremity.

Neurological deficits secondary to compression of the spinal cord or nerve roots also can be part of the presentation:

The degree of neurological compromise can vary from slight weakness or an abnormal reflex to complete paraplegia, depending on the degree of encroachment.

The loss of bowel or bladder continence can occur from neurological compression or can be secondary to a local mass effect from a tumour in the sacrococcygeal region of the spine, as occurs in chordomas.

There may also be motor deficits, paraesthesia, numbness in legs, and loss of sphincter control.

Investigations

ESR, or CRP to help to distinguish between neoplastic and infectious processes.

Elevations in serum calcium or alkaline phosphatase also can provide evidence for neoplastic bone processes. Specific studies such as serum electrophoresis or urine electrophoresis also can be performed to evaluate the likelihood of multiple myeloma or plasmacytoma.

Plain X-ray, CT scan or MRI scan should be requested.

Myelography may also be useful.

Confirmation of diagnosis and ascertaining the specific tumour type is by biopsy of the spine lesion after all radiographic studies have been completed. Biopsy can be performed with open or by percutaneous image-guided technique. Percutaneous needle biopsies may not supply adequate tissue for the diagnosis of a primary tumour of the spine.

Although most are benign, the lesions are locally aggressive and their size and location may not allow complete resection.

Those that cannot be excised should be curetted.

Radiation is reserved for surgically inaccessible tumours.

The recurrence rates can be as high as 40-60%.

Osteochondroma:

Complete surgical resection is usually curative.

Clinical symptoms usually improve following removal of the exostosis.

Incomplete resection can lead to recurrence of the lesion.

Chondrosarcoma:

Complete resection of the vertebra and strut bone grafting may be necessary for complete excision.

Cure is possible when complete resection can be achieved but this is only possible in a minority of cases.

If wide marginal resection cannot be achieved, the tumour recurrence results in death in about 75% of cases. Chemotherapy is used sometimes to help to decrease the size of the mass.

Metastases of chondrosarcoma depend on the grade of the primary chondrosarcoma.

The lungs are the most frequent sites of metastasis.

Ewing's sarcoma:

Before chemotherapy, the survival rate for patients was low.

This was due to the difficulty of resecting these lesions.

Radiation and chemotherapy are the current mainstays of treatment of Ewing's sarcoma in the spine. There is almost 100% local control and 86% long-term survival rate in patients with non-sacral sarcomas.

Sacral tumours have a 60% local control rate and only 25% long-term survival rate.

This is secondary to their tendency for delayed presentation and therefore larger size.

The most important prognostic indicator for survival is response to chemotherapy.

Osteosarcoma:

Surgical resection.

However, resection of spinal lesions is often incomplete due to the size and location of the tumour at the time of presentation.

Adjuvant chemotherapy and radiation therapy often are employed with varying degrees of success.

Spinal osteosarcomas have a dismal prognosis, with deaths usually occurring within the first year of diagnosis.

Only a few patients have been reported to survive longer than two years.

Chordomas:

Surgical resection.

The prognosis depends on whether the tumour can be resected completely.

The location and size at presentation often mean that incomplete resection only is possible.

Patients with sacrococcygeal tumours often have improved survival because the surrounding structures are more expendable and allow better resection.

These patients usually have 8-10 years of survival as opposed to 4-5 years of survival for other spinal sites. Death usually is related to local recurrence and invasion rather than metastatic disease.

Chordomas can metastasise.

The most common sites of metastases are the liver, lungs, regional lymph nodes, peritoneum, skin and heart.

Multiple myeloma:

Generally sensitive to radiation and chemotherapy.

Surgery for stabilisation is indicated in myelomas of the spine when destruction of the vertebral body exists to such an extent that collapse and possible kyphosis with canal compromise could result. Adjuvant radiation therapy may be used postoperatively once healing of the surgical site has been obtained.

Complications

Complications associated with spinal tumours can be divided into the following:

Complications associated with the tumour, its recurrences or its metastases:[1]

Neurological complications include radicular pain or focal weakness from impingement on a nerve root and complete or incomplete paraplegia from direct pressure on the spinal cord (see also separate article Spinal Cord Injury and Compression).

Complications associated with the surgical, radiation or chemotherapeutic treatment of the tumours:

Complications that result from the treatment modality employed may be related to structures sacrificed during the surgical resection to obtain clear margins, structures in the path of radiation therapy or the systemic effects of chemotherapy.

Disclaimer: This article is for information only and should not be used for the diagnosis or treatment of medical conditions. EMIS has used all reasonable care in compiling the information but make no warranty as to its accuracy. Consult a doctor or other health care professional for diagnosis and treatment of medical conditions. For details see our conditions.